Pressure injury prevention and management practices among nurses: A realist case study

Abstract

The prevention and management of a pressure injury is a nurse‐sensitive quality indicator in hospitals. Prevention and management of pressure injury practices have been found to be suboptimal despite the availability of interventions. Currently, there is a poor understanding of the mechanisms behind these interventions. The aim of the study was to explain a realistic portrayal of nurses' current practices to prevent and manage pressure injuries in one public hospital in Singapore. A realistic case study design was adopted. Twenty‐four nurses were recruited. Audio‐recorded interviews were transcribed verbatim to facilitate thematic analysis. Prevention and management was generally facilitated through the timely escalation of care, effective communication, support from the wound nurses, and bridging of the knowledge‐practice gap. However, factors such as nurses' intrinsic characteristics and organisational support may affect the outcomes of these facilitators. Overall, nurses strive to achieve patient safety, where pressure injuries are prevented to the best of their abilities. This study provides causal links between contextual factors, mechanisms of the prevention and management, and the outcomes achieved. Further refinement and testing of the specific mechanisms are needed and will contribute to a better understanding of how nurses prevent and manage pressure injuries.

1. INTRODUCTION

Pressure injury (PI) is defined as “a localized damage to the skin and/or underlying soft tissue usually over a bony prominence.”1 Currently, the worldwide prevalence of PIs in acute settings is estimated to be between 6% and 15%,2 while in Singapore, the latest PI prevalence is reported to be 18.1%.3 This is seen to be a major concern as PIs are often highly regarded to be preventable. Preventing and managing PIs are nurses' responsibility, which includes the assessment and staging of PIs, timely execution of preventive practices, and proper dressing techniques for existing PIs.4 However, studies have identified that these practices are carried out in a suboptimal manner. This was attributed to a myriad of reasons such as poor attitudes,5 lack of knowledge,6 and even organisational constraints.7 Even though care bundles and clinical guidelines were implemented,8 hospital‐acquired PIs are still prevalent. This implies that there is a need for deeper exploration of the effectiveness of these interventions.9 It was identified that these interventions often occur concurrently in health care settings, such that viewing them solely without considering other concurrent components will most likely result in an unrealistic interpretation of the effects of the interventions.10 Thus, this suggests that a holistic understanding of prevention and management of pressure injuries (PMPIs) may be beneficial as it can identify the processes that facilitate better care delivery, which would explain whether the interventions adopted are successful or if new interventions are needed.

1.1. Theoretical framework

The study was guided by the principles of realistic evaluation.11 Four main concepts (context, mechanism, outcomes, and conjectured context‐mechanism‐outcomes configurations [CCMOs]) form the basis of realistic evaluation.11 Mechanisms refer to the causal pathways of programmes and interventions.12 For this study, they are interpreted to be the processes that facilitate and promote PMPIs. Context refers to the conditions that are relevant to the operation of mechanisms.11 They are determined to be both intrinsic (nurses' personal knowledge and attitudes) and extrinsic factors (environment and organisational factors). Outcomes, such as achieving patient safety through reduction of PIs, are perceived to be the intended effects of the mechanisms. Finally, CCMOs refer to transferable lessons derived from the analysis of the relationships between context, mechanisms, and outcomes (CMOs), which will only be derived upon data analysis.12 The realistic framework is presented in Figure 1, which was adapted from the previous study by Williams et al.13

Figure 1.

Theoretical framework (Adapted from Williams, Burton & Rycraft‐Malone, 2013)

The aim of this study was to explore and explain how nurses prevent and manage PIs in one public hospital in Singapore. This study also aimed to identify factors that influence PI prevention and management and the mechanisms through which nurses prevent and manage PIs.

2. METHODS

2.1. Research design

This study used a qualitative, descriptive, and explanatory case study research methodology to allow for an in‐depth understanding of a phenomenon within its real‐life context.14 As PMPI practices are known to vary among the different levels of nurses, this design was adopted to facilitate analysis within, and across, the different levels of nurses in order to attain a holistic understanding of PMPI practices.

2.2. Participants and setting

Participants were recruited from an acute regional hospital in Singapore, where several interventions that facilitate and promote PMPIs are currently adopted into clinical practice. The inclusion criteria were full‐time nurses aged 21 and older, directly involved in PMPIs with at least 1 year of working experience, and currently working in an inpatient, general ward setting. The exclusion criteria were clinicians not responsible for PI prevention and management who were working in specialist outpatient clinics, emergency department, and the operating theatre. A purposive sample of 24 nurses of different levels, including of 5 Enrolled Nurses (ENs), 5 Staff Nurses (SNs), 5 Nurse Clinicians (NCs), 4 Wound Nurses (WNs), 4 Clinical Instructors (CIs), and Senior Nurse Educator (SNE), consented to participate in this study. As the goal of a case study is not statistical generalisation, the small sample size using purposive sampling is adequate to arrive at an analytical generalisation.14 In another case study, the sample size was also small, comprising only nine participants, including one matron, one ward manager, one clinical nurse specialist, one registered nurse, and one support worker, and uncovered the mechanisms nurses used in embedding infection control into practice.13

2.3. Data collection

After obtaining ethical approval from the Centralized Institutional Review Board (CIRB Ref: 2017/2839) and permission from the hospital's Chief Nurse, the data collection period was from October 2017 to December 2017. To cater to the different levels of nurses, two forms of face‐to‐face qualitative data collection methods were used: semi‐structured interviews and focus group discussions. Focus group discussions were conducted among the ENs, SNs, and CIs as it can leverage on interaction data (eg, commenting and agreeing with each other's experiences).15 One‐to‐one semi‐structured interviews were conducted for the WNs, NCs, and SNE as they have varying involvement in PMPIs that goes beyond daily bedside management. The interview topic guide was developed based on the principles of realistic evaluation,11 and was validated by two other experts in the field, to ensure relevancy and content validity.16 Pilot testing of the interview topic guide was also performed to ensure that the questions were understandable and relevant.16 Demographic data such as age, nationality, educational, and year(s) of experience were also collected.

2.4. Data analysis

Ten individual interviews and three focus group discussions (FGDs) were conducted. The duration of the individual interviews ranged from 28 to 50 minutes, whereas the FGDs ranged from 34 to 47 minutes. All audio recordings were transcribed verbatim for data analysis, and the demographic data collected were analysed using descriptive statistics. The data analysis was a continuous and iterative process that occurred right after the first interview to ensure that any modifications to the interview topic guide can be made in light of emerging findings.17

Thematic analysis guided by Braun and Clarke18 was adopted by first transcribing the tape‐recorded interviews verbatim and, second, by reading and rereading the transcripts in order to gain a deeper level of familiarisation. This ensured that complete understanding of the transcripts within its context was grasped, which subsequently facilitated the identification of patterns among the data.18 The rigour and trustworthiness of this case study will be evaluated by the four criteria posited by Lincoln and Guba19—credibility, dependability, confirmability, and transferability.

3. RESULTS

A total of 24 nurses consented to participate, and among them, 2 participants were male, and approximately 20% of them were non‐Singaporeans. The ethnicity of the nurses consists of Chinese, Malay, Indian, Filipino, and Burmese. Age of the participants ranged between 23 and 44 years, and the number of years working in this current hospital ranged between 1.4 and 2.0 years. Further details of the sociodemographic data are presented in Table 1.

Table 1.

Characteristics of participants

Sociodemographic data	Enrolled nurses (ENs)	Staff nurses (SNs)	Nurse educators (SNEs and clinical instructors, CIs)	Wound nurses (WNs)	Nurse clinicians (NCs)
	N (%)	N (%)	N (%)	N (%)	N (%)
Total	5	5	5	4	5
Age (M [SD])	28.90 ± 8.23	33 ± 5.79	32.25 ± 7.37	30.50 ± 4.36	38 ± 4.30
Gender
Male	0	1 (20)	1 (20)	—	—
Female	5 (100)	4 (80)	4 (80)	4 (100)	5 (100)
Nationality
Singaporean	4 (80)	2 (40)	4 (80)	3 (75)	5 (100)
Permanent resident	—	1 (20)	—	1 (25)	—
Non‐Singaporean	1 (20)	2 (40)	1 (20)	—	—
Ethnicity
Chinese	1 (20)	1 (20)	3 (60)	1 (25)	2 (40)
Malay	2 (40)	—	2 (40)	2 (50)	3 (60)
Indian	1 (20)	2 (40)	—	—	—
Others	1 (20)	2 (40)	—	1 (25)	—
Religion
Buddhism	1 (20)	0	1 (20)	1 (25)	1 (20)
Christianity	2 (40)	1 (20)	2 (40)	—	—
Muslim	1 (20)		2 (40)	2 (50)	3 (60)
Hinduism	1 (20)	2 (40)	—	—	1 (20)
Others	—	2 (40)	—	1 (25)	—
Highest education level
NITEC/higher NITEC	3 (60)	—	—	—	—
Advanced diploma	—	2 (40)	1 (20)	1 (25)	2 (40)
Diploma	1 (20)	—	—	—	—
Degree	1 (20)	3 (60)	2 (40)	3 (75)	3 (60)
Masters	—	—	2 (40)	—	—
Years of experience (M [SD])	9.50 ± 8.6	10.50 ± 6.36	11.30 ± 6.30	9.88 ± 2.18	15.6 ± 6.27
Years working in hospital (M [SD])	1.5 ± 0	1.4 ± 0.22	2 ± 0	3.28 ± 0.11	1.8 ± 0.45

Thematic analysis was performed based on the three key components of realistic evaluation—CMOs with seven themes supported by sub‐themes, as shown in Table 2. The interplay between CMOs may inadvertently result in a certain degree of similarity during the description of sub‐themes. This was discerned to be acceptable as the intent of the thematic analysis was to ultimately derive CCMOs, which are essentially the underlying relationships between the CMOs.20 The themes and sub‐themes are supported by quotes denoted with corresponding participant codes (eg, SN1/WN1/ NC1), which are labelled according to their respective designations.

Table 2.

Realistic evaluation depicting themes and sub‐themes

Realist evaluation	Themes	Sub‐themes
Mechanisms: underlying processes that facilitate and promote nurses' PIPM practices	Theme 1: Escalation of care	Intra‐nursing involvement
		Multidisciplinary involvement
	Theme 2: Communication	Face‐to‐face communication
		Use of digital images
		Establishing communication chains
	Theme 3: Support from wound nurses	Making key decisions
		Sharing of workload
	Theme 4: Bridging knowledge‐practice gaps	Keeping up‐to‐date
		Visual demonstration
		Hands‐on practice
Context: intrinsic and extrinsic factors relevant to the operation of the mechanisms	Theme 5: Nurses' intrinsic characteristics	Self‐perceived roles and responsibilities
		Personal attitudes
		Pre‐existing knowledge
	Theme 6: Organisational support	Allocation of physical resources
		Allocation of manpower
		Availability of opportunities
		Ward culture
Outcomes: the effects generated from the mechanisms	Theme 7: Patient safety	Provision of holistic care
		Improving standards of care
		Care continuity

3.1. Mechanisms

Mechanisms refer to the underlying processes that facilitate and promote nurses' prevention and management of pressure injury (PMPI) practices. Four sub‐themes emerged: escalation of care, support from WNs, communication, and bridging knowledge‐practice gaps.

3.1.1. Theme 1: Escalation of care

PI management is largely dependent on appropriate and timely care escalation, especially if it is deemed to be complex. SNs and ENs are usually at the forefront of the escalation pathway. Failure to intervene in a timely manner may result in hospital‐acquired PIs, which warrants a direct escalation to the institutional level. Nurses from different levels displayed awareness regarding the chain of escalation. The ENs, who typically perform basic nursing care, would depend on clinical judgement skills to determine if they should escalate their findings to the SNs.

On admission or when we change diaper, we spot redness or like new pressure ulcer or what, we will just call the SN in‐charge first.—EN1

Because sometimes we are not wound expert like the wound nurse, we will still refer to them for managing extensive PI.—NC3

Proper escalation is deemed to be necessary before patients can receive specialised care from the WNs themselves.

We only see referral only, so that not every patient comes, every pressure injury we interfere—WN1

Beyond the nursing discipline, the multidisciplinary health care team, such as dieticians, may also be involved. This is usually to gather input in areas that are beyond the nursing expertise. In addition, WNs may escalate PI management to the doctors so that they can provide additional input or assist by ordering diagnostic tests.

3.1.2. Theme 2: Communication

Participants highlighted the importance of communication within and across different levels of nurses using different modes of communication related to daily care of PMPIs. Face‐to‐face communication between the SNs and ENs can help to facilitate daily nursing care and to ascertain that preventive care is carried out dutifully.

Sometimes we are busy but we ask for verbal confirmation, like ‐ did you apply cream? Did you turn him? If they say yes, then you just have to trust them.—SN4

In addition, the availability of opportunities that facilitate face‐to‐face communication ensured that different levels of nurses are kept informed before their shift.

…we will have the junior and senior nurses tag along with us to see everybody's butt [backside]to update and see if there is any pressure injuries—NC2

Sharing of photos using messaging platforms was reported to be an effective mode of communication among the nurses, especially when they require input from the NCs.

Sometimes there are no NCs in the ward but you need to keep them informed… so they give instructions after they see the photo via Tiger Text [mobile application].—SN4

Nonetheless, some nurses highlighted concerns such as breach in patients' confidentiality. However, it was agreed that communication using Tiger Text compliments formal chains of communications to ensure continuity of care among the different levels of nurses. One predominant chain of communication—“WNs to NCs to SNs to ENs”—was used to disseminate PMPI practices. WNs also communicate actively with the nurse educator, such that gaps in current knowledge and practices are often reported to the education department so that they can deliver more targeted educational programmes for the nurses.

…they [WNs] also share their concerns about the nurses [SNs & ENs] who don't do correctly. Then I try to emphasize more during in‐service or wound management course—SNE1

3.1.3. Theme 3: Support from wound nurses

Most participants regard WNs to be a significant source of support and key decision‐makers with regard to PMPIs. Their involvement in dressing PIs also helped to alleviate the workload of SNs. WNs are perceived to be content experts by other levels of nurses. As a result, important decisions regarding PIs were usually left to the WNs, while SNs and NCs focus on ensuring that these decisions are carried out during clinical practice.

Usually the WNs will decide what dressing material to use, how frequent to change all those. We will just follow up accordingly—SN2

This was supported by the WNs themselves, where they displayed awareness that their decisions have significant weightage and, hence, strive to provide well‐rationalised and patient‐centred decisions.

We will see the condition of the wound before we decide? Then we have to see and tailor it to their financial status—WN3

Furthermore, WNs co‐managed PI dressings with the SNs, which is perceived by some SNs to be a convenience as it alleviates their workload.

3.1.4. Theme 4: Bridging knowledge‐practice gaps

Most nurses perceive knowledge translation to be important for improving PMPI practices. Three significant aspects were reported to facilitate knowledge translation: keeping updated with the latest information regarding PMPI, learning through visual demonstration of skills, and having hands‐on practices. Nurses highlighted the importance of having an updated knowledge base by periodically refreshing their PMPI knowledge through in‐services and courses.

It [Educational courses] is kind of a refresher for us because we already know the basic prevention all those already. So in‐services all those is mostly like an update about newer dressing materials from the vendors—SN1

Some nurses also highlighted the importance of the applicability of the knowledge taught during courses. There was a preference for case studies, where they can apply their knowledge to realistic scenarios. Visual demonstration and observing WNs were also regarded to be an integral aspect for the application of knowledge to practice.

Maybe can show more of the pictures of the PIs, and let the nurses do by suggesting how do they stage and what sort of management do they need—CI2

…you learn from WNs what they are doing so that next time we know how to do ourselves. Then you got any question, you can just ask them.—SN4

A majority of the nurses regarded having hands‐on practice to be an essential aspect in bridging knowledge‐practice gaps. WNs highlighted that the clinical presentation of PIs varies significantly. Therefore, having hands‐on practice is comparable, if not more significant, than having theoretical knowledge.

3.2. Context

Context refers to the intrinsic and extrinsic factors relevant to the operation of the mechanisms.11 Two sub‐themes were identified: nurses' intrinsic characteristics and organisational support.

3.2.1. Theme 5: Nurses' intrinsic characteristics

Nurses' personal characteristics and their inherent predispositions were seen to have a direct impact on the mechanisms, which may inadvertently affect the manner in which PMPI care is delivered. The importance of having a positive learning attitude was highlighted by most nurses. Being proactive about learning was seen to be the crux for knowledge and skill acquisition, especially in terms of bedside education from the WNs.

You must be proactive… there's a lot about ourselves as well, we must be willing to go in and learn from them and ask them if we don't know—SN1

Nonetheless, WNs reported that learning attitudes are highly subjective and dependent on the individual.

Some people really want to come in and observe, and they really want to learn. But some it's like, leave it to the wound nurse…—WN1

Beyond learning attitudes, some participants felt that it boils down to individual's perceived importance for PIs. If they do not see it as a critical aspect of nursing care, they are less likely to carry out care related to PMPIs and, thus, may not be quick enough in picking up early signs so that they can escalate it in a timely manner.

…they really must actively look out and prevent PIs… if they don't see the need then it's difficult for them to know whether the patient can develop PIs—CI4

In addition, perceived importance of PMPIs will also determine the amount of effort nurses put in in terms of keeping themselves updated regarding patients' PIs. Background knowledge was regarded by the nurses to be an important aspect for risk and skin assessment to discern PI risks.

First thing we would be doing is a visual inspection of the skin… and from that we will be able to know the risks or the staging, as per our background knowledge.—SN3

The ENs, however, emphasised that their knowledge on skin assessment is incomplete, and the responsibility of skin assessment rests mostly on the SNs. Furthermore, they believed that the lack of knowledge does not affect their risk escalation practices.

Actually we don't really do staging like this is Stage 4 or Stage 5. We see red is red, bad is bad, staff nurse come and see.—EN3

Nonetheless, WNs highlighted that differences in terms of knowledge between the SNs and WNs may inadvertently affect the co‐management of PI wounds. Nurses' perceptions of their own job scopes, as well as that of other levels of nurses, may influence the way nurses communicate and escalate potential PIs. In general, ENs and SNs perceive that their key responsibility lies with PI prevention rather than PI management.

As staff nurses the number one most important thing we would be able to do is to assess the patients’ need for PI prevention—SN2

NCs, however, shared that their role is to ensure the quality of PMPI care, where part of their role lies in being a mediator and an agent of communication. Self‐perceived job scopes may also result in reduced opportunities for ENs to have hands‐on practice, which may further exacerbate the knowledge‐practice gap.

…when they encounter any problems, they will tell me what is it… then we advise what is the appropriate things to do, and disseminate to the nurses—NC2

3.2.2. Theme 6: Organisational support

Organisational support was seen as the main extrinsic factor that affects nurses' delivery of care for PMPIs, such as access to resources, educational opportunities, and manpower. Currently, these are sufficient for PMPIs. Nurses reported that:

The organization is supportive in terms of prevention. The air mattress installation is already free. Most of the cream to prevent pressure ulcers are all available.—SN1

However, participants reported that accessibility and availability of WNs are needed as there are only four WNs currently employed in the hospital. Furthermore, their working hours exclude weekends and, hence, was perceived to be a manpower barrier that limits the support that they can otherwise provide.

We don't have a lot of wound nurses, and they don't work on weekends and see cases only based on referrals. And also they belong to one or two wards only—SNE1

Nurses emphasised the importance of having sufficient learning opportunities. This ranged from being able to attend educational courses to having sufficient exposure and practice for PIs. Fostering a positive ward culture was also perceived to be an important organisational factor for maximising the mechanisms that facilitate PMPIs. In particular, a culture that focuses on the importance of communication will, in turn, put in more effort in creating opportunities to enhance face‐to‐face communication. In addition, nurses perceived that a culture that emphasises on teamwork is imperative in ensuring that potential PIs can be assessed and escalated in a timely manner.

This one [Weekly butt day] is our ward, we create our own thing and make another effort to check the patients together every week—NC1

3.3. Outcomes

Outcomes refer to the effects of the aforementioned mechanisms.21 It is deemed to be the result of the interplay between the context and the mechanisms. An overarching sub‐theme, patient safety, encompassed the outcomes identified from the nurses in this study.

3.3.1. Theme 7: Patient safety

Provision of holistic care, ensuring continuity of care, and improving standards of care ensured that PIs are adequately prevented and that any existing PIs are treated efficiently and effectively. As such, patients can be kept safe, which is the key outcome of PMPI practices.

Care continuity was highlighted to be an integral aspect in ensuring patient safety.

…we [WNs] can tell if they follow our instructions… so far it's actually not that bad ‐ there has been continuity.—WN3

However, in some instances, broken communication can result in a lack of care continuity, where WNs' instructions were not carried out appropriately. This results in poor management of PIs, which was highlighted to be unfair to patients and a breach in patient safety.

Halfway through they will just change to another product without informing us… then they say, I'm not sure what happened on the way.—WN4

The provision of holistic care was highlighted by several participants. Nurses identified that, through appropriate escalation, patients would be able to achieve input from various expertise.

It is a responsibility as a team to ensure a holistic approach so patients can achieve care from different experts.—SN2

With more people involved then different aspects of care can be covered, which is good since wound healing is more than just the wound.—NC1

3.4. CCMO configurations

The crux of realistic evaluation lies in the derivation of CCMO configurations. Typically, well‐constructed CCMOs encompass key findings from CMOs and, thereafter, serve to provide a succinct explanation of the links between these components.22 In this study, five CCMOs were established after an iterative process of clarifying links between aforementioned themes and sub‐themes (Table 3). These CCMOs explained how nurses prevent and manage PIs within the context of the hospital, which corresponds to the overall aim of the study.

Table 3.

Conjectured context‐mechanisms‐outcomes configurations

CCMO 1	Nurses' knowledge, perceived importance, and subsequent involvement in prevention and management of pressure injury (PMPI) may influence the rate and scope of escalation, which can thereafter affect the provision of holistic care.
CCMO 2	Presence of communication agents, along with a culture of teamwork, can maximise opportunities for supportive communication regarding PMPI, which enhances the coordination and continuation of care.
CCMO 3	Wards that demonstrate receptiveness towards the adoption of technological innovations may be more inclined to use novel forms of communication (usage of digital images), which can enhance the continuity of care for patients with pressure injuries (PIs).
CCMO 4	Organisational commitment maximises the support from wound nurses, which can henceforth raise the overall standards for PMPI practices.
CCMO 5	Positive learning attitudes, coupled with a supportive environment, can increase the propensity to bridge existing knowledge‐practice gaps for PMPI, such that a higher quality of care can be collectively established.

4. DISCUSSION

This study aimed to explain a realistic portrayal of nurses' current practices to prevent and manage PIs in one public hospital in Singapore. Compared with other studies,23, 24 the participants' ethnicity is significantly more diverse because of Singapore's multiracial society and the tendency to hire non‐Singaporean nurses to compensate for the shortage of local nurses.25 Another significant aspect of the sociodemographic data lies in the relative homogeneity for nurses' years of experience working (1‐2 years) as this study hospital has only been established for 3 years.

4.1. CCMO 1—Escalation of care

Nurses in this study elucidated the presence of an informal care escalation pathway, which is predominantly initiated by the ENs and subsequently escalated to the SNs for formal risk and skin assessment. Interestingly, several nurses rationalised that the escalation of care is not entirely attributed to the lack of knowledge but, rather, their personal perceptions that they have limited autonomy. They prefer to inform the superiors, a phenomenon attributed to the nursing hierarchy, which could be deeply entrenched in Asian societies.26 Being at the bottom of the hierarchy, ENs are involved in labour‐intensive bedside care, which resulted in them being placed at the forefront of the PMPI care escalation pathway. However, a more in‐depth exploration of the PMPI risk escalation pathway may be warranted to generalise the findings beyond the Asian context.

Because of the role of ENs in activating the PMPI escalation pathway, ENs' knowledge on risk and skin assessment is henceforth of utmost importance. In this study, ENs reported that they lack knowledge for PI staging and assessment, yet they do not perceive it to be an issue as they felt that SNs are the ones who can assess the stage of the PI.27 However, some nurses insinuated that SNs focus heavily on other aspects and neglect bedside care. This finding concurs with that reported by Sving et al28 and Samuriwo,29 where they attributed this phenomenon to be a result of heavy SN workload, as well as implicit trust and confidence in the ENs. Their reasons could be extrapolated to explain the findings in this context, especially as Singapore has a high nurse‐to‐patient ratio, which can provide a rough indicator of SNs' daily workload.30 Thus, SNs may be more inclined to rely on ENs' escalation rather than being involved in bedside PMPI care.

Overall, nurses emphasised that the desired outcome of risk escalation is to attain holistic care for PMPIs. This is beneficial as involving specialty nurses and other allied health care members increases the combined vigilance, such that the relevant risk factors for PI development can be monitored closely to prevent any potential deterioration.29 A multidisciplinary approach is also advocated in most best practice guidelines and recommendations. Therefore, it can be ascertained that what nurses in this study perceived to be important aligns well with international recommendations.1, 4

4.2. CCMO 2—Maximising opportunities for communication

Findings from this study identified two main communication systems that run concurrently to facilitate communication across different levels of nurses. The first communication system included two feedback loops. The first feedback loop was established between key nurses who hold significant positions with regard to PMPI (ie, WNs, NCs, and the NEs). WNs would provide feedback regarding any lapses in practices to the NCs, such that they can disseminate it to the SNs. This first feedback loop is established on the basis of performance management, where managers such as NCs are perceived to be the quality control point31 and that their instructions will carry sufficient weightage for the SNs to ensure that their current PMPI practices meet the expected standards. In the second feedback loop, the WNs provide feedback about current PMPI practices to the NEs and SNs so that targeted educational programmes that can be delivered to them. Most importantly, the continuation of these feedback loops is heavily reliant on nurses' self‐perceived roles and responsibilities, where nurses must first be aware of their role as a communication agent.

The second communication system occurs within the boundaries of the ward, where effective communication between ENs, SNs, and NCs can help to ensure the coordination of daily PMPI duties. This communication is established based on trust and teamwork between the ENs and SNs. The NCs establish opportunities for face‐to face communication, where they join the ENs’ and SNs’ weekly rounds regarding patients' PI risk status. Face‐to‐face communication was highlighted to be the preferred mode of communication among the different nurses as it could be attributed to efficiency and credibility, especially as face‐to‐face communication can enhance non‐verbal communication.32

4.3. CCMO 3—Adopting novel forms of communication

Nurses identified that part of the communication associated with PMPIs involves the use of digital images, which are sent through an institutional‐approved messaging application that is accessible on mobile platforms and hospital intranet. Sending photographs using the Tiger Text to nurses in the same ward facilitates communication between them and ensures that the NCs are kept updated of PIs. Such forms of communication may sometimes be used by NCs to provide input on the management of the PI based on the photograph. A study found that assessing wounds in digital high‐resolution images has no significant differences in terms of accuracy compared with real‐time physical wound assessment.33 In our study, communication through photo sharing involves the use of nurses' own mobile devices for photo taking, and these photographs are used only as an adjunct, informal form of communication, where proper follow up using formal communication platforms such as nursing documentation and verbal communication are still heavily relied upon.

4.4. CCMO 4—Support from WNs

Nurses in this study generally regarded WNs to be of a significant source of support and trust in making key decisions for PMPIs. This trust is highly justified, especially because WNs in Singapore undergo specialised trainings and receive accreditation from the International Wound, Ostomy, and Continence Nursing Certification Board. In a society that places so much emphasis on certification as a form of validation, SNs in Singapore may regard the instructions of WNs to be of high importance and, as such, will adhere closely to their instructions for PMPIs.

Other studies also highlighted alternative forms of support that WNs may provide for PMPIs.34, 35 WNs were considered to be an intermediary that can influence PI prevention based on their visibility and surveillance, and their presence can stimulate nurses to strictly adhere to PMPI practices. This has the propensity to significantly improve PMPI practices; however, it was not identified in this study. One possible reason could be because of the limited availability of WNs in Singapore. The lack of WNs in this hospital may indicate that the organisation considers WNs to have low importance and value. Thus, to optimise the benefits of WNs, organisational support and commitment is crucial.

4.5. CCMO 5—Bridging theory‐practice gaps

Positive learning attitudes, coupled with a supportive environment, can increase the propensity to bridge existing theory‐practice gaps for PMPIs. Nurses identified that education for PMPI using case studies was preferred as it can facilitate knowledge application. This finding concurred with other studies, such as that of Gould and Chamberlain,36 on the education for infection control practices. The similarity in findings could be because of the nature of wound care and infection control, where emphasis is placed on nurses' acquisition of skills.37

Nurses also emphasised the support of the environment, where the onus for creating sufficient learning opportunities rests heavily on the organisation. Moore and Cowman37 identified that nurses in general possess a positive attitude towards learning for PMPIs but were significantly impeded by a lack of time and staff. Most nurses may not have the luxury of time to partake in bedside education during clinical hours. Furthermore, findings in this study showed that the limited availability of slots for official educational programmes such as wound courses may impede nurses' opportunity for knowledge acquisition. As a result of these organisational barriers, nurses' opportunities for learning may be diminished even if they possess positive learning attitudes towards PMPIs. With today's health care climate, it is unlikely that health care organisations will be able to eradicate staffing and time constraints such that learning can be facilitated.38 Therefore, it may be prudent for health care organisations to focus on maximising selected learning opportunities that nurses deem to be the most effective. Plausibly, establishing protected time during clinical hours for SNs to shadow WNs may be helpful, although more studies exploring possible solutions for the maximisation of PMPI learning opportunities may be needed. This is of utmost importance as bridging theory‐practice gaps ensure that updated knowledge is transferred to clinical practice, which can thereafter facilitate the provision of higher‐quality PMPI care. Constantly striving to improve the quality of care provided can ensure that practices are congruent with best practice recommendations, which ultimately serve to increase patient safety.39

4.6. Limitations of the study

This study has a few limitations. First, the lack of older nurses in this study may inadvertently result in an unfair representation of the views of the older generation, especially those not digitally competent in using the Tiger text. Second, participant observation, which is usually performed in case study research to increase robustness, was not performed for this case study because of time constraints. Finally, the generalisability of this study's findings may also be limited as this study used a qualitative single case study research design. As such, further work should be conducted to test the findings in other contexts and settings, such that refinement of the newly established CCMOs can take place.

4.7. Implications of the study

Findings in this study highlighted that the applicability of knowledge is more important compared with the provision of theoretical knowledge. As such, future education for PMPIs should focus more on providing hands‐on opportunities, allowing nurses to gain knowledge through application rather than conventional pedagogical methods. Furthermore, different levels of nurses require different types of knowledge. For instance, ENs require high levels of knowledge and exposure with regard to identifying early signs of PIs but not so much on proper staging and documentation of PIs. Thus, it is imperative that education on PMPIs is catered to the roles of the nurses. Findings have also shown that health care organisations should be more attuned to the needs of the nurses with regard to manpower and resource allocation. In particular, ensuring that there are enough WNs to support the needs of the system is regarded to be of high importance, especially because they possess specialised skill sets that are valuable in clinical practice. Furthermore, health care organisations should ensure that they have sufficient resources, such that PMPI care will not be impeded because of limited resources.

5. CONCLUSION

This study found that different levels of nurses have different roles to play in PMPIs but in a complementary manner in nature, by understanding the underlying processes and intrinsic and extrinsic factors relevant to the operations of the mechanisms in bridging knowledge‐practice gaps. The five CMO configurations highlighted the need for health care organisation's support of those who seek improvements in PMPI practices to work from within to provide a ward environment that facilitates practice‐based teaching, open communication, and seamless escalation of PI prevention and management at all levels.

Teo CSM, Claire CA, Lopez V, Shorey S. Pressure injury prevention and management practices among nurses: A realist case study. Int Wound J. 2019;16:153–163. 10.1111/iwj.13006